Provider First Line Business Practice Location Address:
17720 NE HALSEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-6734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-654-7654
Provider Business Practice Location Address Fax Number:
503-654-7333
Provider Enumeration Date:
01/15/2015